West Side Story 2: Neurologists And Psychiatrists Rumble

If something’s wrong with your brain, should you see a psychiatrist or a neurologist? The answer to that question depends on whether modern medicine can tell you why you’re sick.

Here’s the simplified breakdown these days: people suffering from neurodegeneration, stroke, or traumatic brain damage see neurologists. People with anxiety disorders, depression, or psychosis see psychiatrists.

Fine, but how was this distinction made? Is it based on the symptoms of the illnesses?

We tend to think that neurologists see patients with motor (e.g., Huntington’s) or cognitive (e.g., Alzheimer’s) impairments, yet psychiatric illnesses can include motor and cognitive symptoms (e.g., schizophrenia).

And we tend to think that psychiatrists see people with emotional problems, yet neurological illnesses can have emotional symptoms. For example, depression often precedes motor problems in Parkinson’s disease.

No, the distinction is based on what we know and can see. Neurology covers observable or testable brain diseases (although sometimes they can’t observe the pathology until after death). Neurologists can locate the damaged tissue from a stroke, the aberrant neural activity characteristic of epilepsy, or the subcellular aggregate proteins that indicate certain types of degeneration. This is considered real medicine, based on hard science. And when the causes, or at least the pathology, of an illness are known, medicine can more systematically diagnosis and treat it.

That’s what neurologists have to work with. The leftovers go to psychiatrists. These are the illnesses with no overt physical pathology. Even though something is clearly wrong with a psychotic individual, we don’t know exactly how or where in the brain to look for definitive evidence, and not knowing means we’re in the dark on treatment. We use the drugs that work without knowing why they do.

In the course of my interactions with both scientists and physicians, many have expressed the view that the field of psychiatry is essentially voodoo. They say that psychiatrists throw drugs at patients without rhyme or reason, and that researchers of mental illnesses search in vain for the causes of loosely classified, ill-defined disorders.

Clearly this assessment isn’t fair. Psychiatry is left with only those diseases we don’t understand and can’t see. Thus, treatment is a guessing game. Then, when psychiatrists step up and try to help the millions of suffering patients, they’re pooh-poohed for the messy, hand-waving black magic of it all.

Once scientists find reliable physiological markers for mental illnesses, psychiatrists can have their laugh. That is, until the neurologists take their patients.

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